Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. STUDY DESIGN: Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. RESULTS: A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. CONCLUSIONS: NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

The more you have, the more you lose: Muscle mass changes in trauma patients with prolonged hospitalizations.

INTRODUCTION: Sarcopenia is a clinically relevant loss of muscle mass with implications of increased morbidity and mortality in adult trauma populations.  Our study aimed to evaluate loss of muscle mass change in adult trauma patients with prolonged hospital stays. METHODS: Retrospective analysis using institutional trauma registry to identify all adult trauma patients with hospital length of stay >14 days admitted to our Level 1 center between 2010 and 2017. All CT images were reviewed, and cross-sectional area (cm2) of the left psoas muscle was measured at the level of the third lumbar vertebral body to determine total psoas area (TPA) and Total Psoas Index (TPI) normalized for patient stature.  Sarcopenia was defined as a TPI on admission below gender specific thresholds of 5.45(cm2/m2) in men and 3.85(cm2/m2) in women.  TPA, TPI, and rates of change in TPI were then evaluated and compared between sarcopenic and non-sarcopenic adult trauma patients. RESULTS: There were 81 adult trauma patients who met inclusion criteria. The average change in TPA was -3.8 cm2 and TPI was -1.3 cm2. On admission, 23% (n = 19) of patients were sarcopenic while 77% (n = 62) were not. Non-sarcopenic patients had a significantly greater change in TPA (-4.9 vs. -0.31, p<0.0001), TPI (-1.7 vs. -0.13, p<0.0001), and rate of decrease in muscle mass (p = 0.0002). 37% of patients who were admitted with normal muscle mass developed sarcopenia during admission.  Older age was the only risk factor independently associated with developing sarcopenia (OR: 1.04, 95%CI 1.00-1.08, p = 0.045). CONCLUSION: Over a third of patients with normal muscle mass at admission subsequently developed sarcopenia with older age as the primary risk factor. Patients with normal muscle mass at admission had greater decreases in TPA and TPI, and accelerated rates of muscle mass loss compared to sarcopenic patients.

Smartphone imaging repository: a novel method for creating a CT image bank.

BACKGROUND: Imaging repositories are commonly attached to ongoing clinical trials, but capturing, transmitting, and storing images can be complicated and labor-intensive. Typical methods include outdated technologies such as compact discs. Electronic file transfer is becoming more common, but even this requires hours of staff time on dedicated computers in the radiology department. METHODS: We describe and test an image capture method using smartphone camera video-derived images of brain computed tomography (CT) scans of traumatic intracranial hemorrhage. The deidentified videos are emailed or uploaded from the emergency department for central adjudication. We selected eight scans, mild moderate, and severe subdural and multicompartmental hematomas and mild and moderate intraparenchymal hematomas. Ten users acquired data using seven different smartphones. We measured the time in seconds it took to capture and send the files. The primary outcomes were hematoma volume measured by ABC/2, Marshall scale, midline shift measurement, image quality by a contrast-to-noise ratio (CNR), and time to capture. A radiologist and an imaging scientist applied the ABC/2 method and calculated the Marshall scale and midline shift on the data acquired on different smartphones and the PACS in a randomized order. We calculate the intraclass correlation coefficient (ICC). We measured image quality by calculating the contrast-to-noise ratio (CNR). We report summary statistics on time to capture in the smartphone group without a comparator. RESULTS: ICC for lesion volume, midline shift, and Marshall score were 0.973 (95% CI 0.931, 0.994), 0.998 (95% CI: 0.996, 0.999), and 0.973 (0.931, 0.994), respectively. Lesion conspicuity was not different among the image types via assessment of CNR using the Friedman test, [Formula: see text] of 24.8, P = < .001, with a small Kendall's W effect size (0.591). Mean (standard deviation) time to capture and email the video was 60.1 (24.3) s. CONCLUSIONS: Typical smartphones may produce video image quality high enough for use in a clinical trial imaging repository. Video capture and transfer takes only seconds, and hematoma volumes, Marshall scales, and image quality measured on the videos did not differ significantly from those calculated on the PACS.

Agitation in the Trauma Bay Is an Early Indicator of Hemorrhagic Shock.

INTRODUCTION: Agitation on arrival in trauma patients is known as a sign of impending demise. The aim of this study is to determine outcomes for trauma patients who present in an agitated state. We hypothesized that agitation in the trauma bay is an early indicator for hemorrhage in trauma patients. METHODS: We performed a single-institution prospective observational study from September 2018 to December 2020 that included any trauma patient who arrived agitated, defined as a Richmond Agitation-Sedation Scale of +1 to +4. Variables collected included demographics, mechanism of injury, admission physiology, blood alcohol level, toxicity screen, and injury severity. The primary outcomes were need for massive transfusion (≥ 10 units) and need for emergent therapeutic intervention for hemorrhage control (laparotomy, preperitoneal pelvic packing, sternotomy, thoracotomy, or angioembolization). RESULTS: Of 4657 trauma admissions, 77 (2%) patients arrived agitated. Agitated patients were younger (40 versus 46, P = 0.03), predominantly male (94% versus 66%, P < 0.0001) sustained more penetrating trauma (31% versus 12%, P < 0.0001), had a lower systolic blood pressure (127 versus 137, P < 0.0001), and a higher Injury Severity Score (17 versus 9, P < 0.0001). On multivariable logistic regression, agitation was independently associated with massive transfusion (odds ratio: 2.63 [1.20-5.77], P = 0.02) and emergent therapeutic intervention for hemorrhage control (odds ratio: 2.60 [1.35-5.03], P = 0.005). CONCLUSIONS: Agitation in trauma patients may serve as an early indicator of hemorrhagic shock, as agitation is independently associated with a two-fold increase in the need for massive transfusion and emergent therapeutic intervention for hemorrhage control.

If at First You Do Not Succeed: Consideration of Attempts in Patients With Trauma.

INTRODUCTION: Failed extubation in critically ill patients is associated with poor outcomes. In critically ill trauma patients who have failed extubation, providers must decide whether to proceed with tracheostomy or attempt extubation again. The aim of this study was to describe the natural history of failed extubation in trauma patients and determine whether tracheostomy or a second attempt at extubation is more appropriate. METHODS: Trauma patients admitted to our level I trauma center from 2013 to 2019 were identified. Patients who failed extubation, defined as an unplanned reintubation within 48 h of extubation, were included. Patients who immediately underwent tracheostomy were compared with those who had subsequent attempts at extubation. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) length of stay (LOS), ventilator days, and hospital LOS. RESULTS: The population included 93 patients who failed extubation and met inclusion criteria. A total of 53 patients were ultimately successfully extubated, whereas 40 patients underwent a tracheostomy. There was no statistically significant difference in demographics or injury patterns. Patients who underwent tracheostomy had a longer ICU LOS and more ventilator days. There was no difference in mortality or hospital LOS between the two groups. CONCLUSIONS: In trauma patients, those who underwent subsequent attempts at extubation did not experience higher rates of mortality than those who received a tracheostomy. Tracheostomy was associated with longer ICU LOS and ventilator days. In certain situations, it is appropriate to consider subsequent attempts at extubation in trauma patients who fail extubation rather than proceeding directly to tracheostomy.

Chest and Pelvis X-Rays as a Screening Tool for Abdominal Injury in Geriatric Blunt Trauma Patients.

BACKGROUND: This study evaluates the utility of chest (CXR) and pelvis (PXR) X-ray, as adjuncts to the primary survey, in screening geriatric blunt trauma (GBT) patients for abdominal injury or need for laparotomy. METHODS: We performed a retrospective analysis of patients 65-89 years in the 2014 National Trauma Data Bank. X-ray injuries were identified by ICD9 codes and defined as any injury felt to be readily detectable by a non-radiologist. X-ray findings were dichotomized as "both negative" (no injury presumptively apparent on CXR or PXR) or "either positive" (any injury presumptively apparent on CXR or PXR). Rates of abdominal injuries and laparotomy were compared and used to calculate sensitivity and specificity. The primary outcomes were abdominal injury and laparotomy. The secondary outcomes included mortality, ventilator days, and hospital days. RESULTS: A total of 202 553 patients met criteria. Overall, 9% of patients with either positive X-rays had abdominal injury and 2% laparotomy vs. 1.1% and .3% with both negative (P < .001). The specificity for any positive X-ray was 79% for abdominal injury and 78% for laparotomy. The sensitivity was 69% for abdominal injury and laparotomy. The either positive group had fewer ventilator days (.3 vs. .8, P < .0001), longer length of stay (7 vs. 5, P < .0001), and higher mortality (6% vs. 4%, P < .0001) vs both negative. CONCLUSION: CXR and PXR can be used to assess for intra-abdominal injury and need for laparotomy. GBT patients with either positive X-rays should continue workup regardless of mechanism due to the high specificity of this tool for abdominal injury and need for laparotomy.

A national trauma data bank analysis of large animal-related injuries.

INTRODUCTION: Large animal-related injuries (LARI) are relatively uncommon, but, nevertheless, a public hazard. The objective of this study was to better understand LARI injury patterns and outcomes. MATERIALS AND METHODS: We performed a retrospective review of the 2016 National Trauma Data Bank and used ICD-10 codes to identify patients injured by a large animal. The primary outcome was severe injury pattern, while secondary outcomes included mortality, hospital length of stay, ICU admission, and mechanical ventilation usage. RESULTS: There were 6,662 LARI included in our analysis. Most LARI (66%) occurred while riding the animal, and the most common type of LARI was fall from horse (63%). The median ISS was 9 and the most severe injuries (AIS ≥ 3) were to the chest (19%), head (10%), and lower extremities (10%). The overall mortality was low at 0.8%. Compared to non-riders, riders sustained more severe injuries to the chest (21% vs. 16%, p<0.001) and spine (4% vs. 2%, p<0.001). Compared to motor vehicle collisions (MVC), riders sustained fewer severe injuries to the head (10% vs. 12%, p<0.001) and lower extremity (10% vs. 12%, p=0.01). Compared to auto-pedestrian accidents, non-riders sustained fewer severe injuries to the head (11% vs. 19%, p<0.001) and lower extremity (10% vs. 20%, p<0.001). CONCLUSION: Patients involved in a LARI are moderately injured with more complex injuries occurring in the chest, head, and lower extremities. Fall from horse was the most common LARI mechanism. Overall mortality was low. Compared to non-riders, riders were more likely to sustain severe injuries to the chest and spine. Severe injury patterns were similar when comparing riders to MVC and, given that most LARI are riding injuries, we recommend trauma teams approach LARI as they would an MVC.

Risk scoring models fail to predict pulmonary embolism in trauma patients.

BACKGROUND: We aimed to identify risk factors and risk scoring models to help identify post-traumatic pulmonary embolisms (PE). METHODS: We performed a retrospective review (2014-2019) of all adult trauma patients admitted to our Level I trauma center that received a CT pulmonary angiogram (CTPA) for a suspected PE. A systematic literature search found eleven risk scoring models, all of which were applied to these patients. Scores of patients with and without PE were compared. RESULTS: Of the 235 trauma patients that received CTPA, 31 (13%) showed a PE. No risk scoring model had both a sensitivity and specificity above 90%. The Wells Score had the highest area under the curve (0.65). After logistic regression, no risk scoring model variables were independently associated with PE. CONCLUSIONS: In trauma patients with clinically suspected PE, clinical variables and current risk scoring models do not adequately differentiate patients with and without PE.

A Prospective Study of Family Satisfaction Changes After Tracheostomy Placement in Trauma Patients.

BACKGROUND: Tracheostomy is a commonly performed procedure in surgical intensive care units. Although the indications and benefits of this procedure are well known, little has been studied in the adult surgical/trauma population about patient family satisfaction after tracheostomy placement. MATERIALS AND METHODS: We performed a prospective study at our academic level I trauma center from 2015-2016 in patients who underwent elective tracheostomy. Family members were asked to complete an eight-point questionnaire using a forced Likert scale of graded responses. Questionnaires were administered prior to tracheostomy and again at 24-and 72-hour post-tracheostomy placement. Responses were compared using univariate analysis. RESULTS: A total of 26 family members completed all 3 surveys. Family members believed loved ones appeared more comfortable, were more interactive, and were better progressing clinically. After 72 hours, family members felt less anxiety. There was no difference in perceptions of patient distress, ability to provide support, or their worry about scars, or comfort in visiting them. DISCUSSION: Family members believed tracheostomies provided greater patient comfort, increased interactive abilities, better progress in their care, and experienced less anxiety after placement. Family satisfaction may therefore be an additional benefit in support of earlier tracheostomy.

Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury?

BACKGROUND: Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI. METHODS: We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement. RESULTS: Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10). CONCLUSION: Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI. LEVEL OF EVIDENCE: Diagnostic, level II.

Fix it while you can Mortality after umbilical hernia repair in cirrhotic patients.

BACKGROUND: We hypothesize that patients with compensated cirrhosis undergoing elective UHR have an improved mortality compared to those undergoing emergent UHR. METHOD: The NIS was queried for patients undergoing UHR by CPT code, and ICD-10 codes were used to define separate patient categories of non-cirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC). RESULTS: A total of 32,526 patients underwent UHR, 97% no cirrhosis, 1.1% compensated cirrhosis, 1.7% decompensated cirrhosis. On logistic regression, cirrhosis was found to be independently associated with mortality (OR 2.841, CI 2.14-3.77). On subset analysis of only cirrhosis patients, elective repair was found to be protective from mortality (OR 0.361, CI 0.15-0.87, p = 0.02). CONCLUSIONS: In this retrospective review, cirrhosis as well as emergent UHR in cirrhotic patients were independently associated with mortality. More specifically, electively (rather than emergently) repairing an umbilical hernia in cirrhotic patients was independently associated with a 64% reduction in mortality.

Desmopressin is a transfusion sparing option to reverse platelet dysfunction in patients with severe traumatic brain injury.

BACKGROUND: Platelet dysfunction (PD) is an independent predictor of mortality in patients with severe traumatic brain injury (sTBI). Platelet transfusions (PLTs) have been shown to be an effective treatment strategy to reverse platelet inhibition. Their use is contingent on availability and may be associated with increased cost and transfusion-related complications, making desmopressin (DDAVP) attractive. We hypothesized that DDAVP would correct PD similarly to PLTs in patients with sTBI. METHODS: This retrospective study evaluated all blunt trauma patients admitted to an urban, level 1 trauma center from July 2015 to October 2016 with sTBI (defined as head abbreviated injury scale [AIS] ≥3) and PD (defined as adenosine diphosphate [ADP] inhibition ≥60% on thromboelastography) and subsequently received treatment. Per our institutional practice, patients with sTBI and PD are transfused one unit of apheresis platelets to reverse inhibition. During a platelet shortage, we interchanged DDAVP for the initial treatment. Patients were classified as receiving DDAVP or PLT based on the initial treatment. RESULTS: A total of 57 patients were included (DDAVP, n = 23; PLT, n = 34). Patients who received DDAVP were more severely injured (injury severity score, 29 vs. 23; p = 0.045), but there was no difference in head AIS (4 vs. 4, p = 0.16). There was no difference between the two groups in admission platelet count (244 ± 68 × 10/µL vs. 265 ± 66 × 10/µL, p = 0.24) or other coagulation parameters such as prothrombin time, partial thromboplastin time, or international normalized ratio. Before treatment, both groups had similar ADP inhibition as measured by thromboelastography (ADP, 86% vs. 89%, p = 0.34). After treatment, both the DDAVP and PLT groups had similar correction of platelet ADP inhibition (p = 0.28). CONCLUSION: In patients with severe traumatic brain injury and PD, DDAVP may be an alternative to PLTs to correct PD. LEVEL OF EVIDENCE: Therapeutic, level IV.

Does tranexamic acid really work in an urban US level I trauma center? A single level 1 trauma center's experience.

BACKGROUND: The use of Tranexamic Acid (TXA) in trauma patients remains controversial. The CRASH II trial, while randomized and prospective, did not include patients suffering from major bleeding. We wanted to examine our population of patients who underwent a massive transfusion protocol (MTP) (greater than 10 Units of packed red blood cells in the first 24 h of admission) to see if those who were undergoing massive transfusion and received TXA had any benefit in mortality. Our hypothesis was that massively transfused patients who received TXA and those that did not had no difference in mortality. METHODS: We performed a single institution retrospective review of our Trauma Registry for all patients who received a massive transfusion between 2010 and 2017. Patients were separated into two cohorts, those who received TXA within the first 24 h of admission and those who did not. The primary outcome of the study was mortality. Secondary outcomes included total blood products transfused, Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), Myocardial Infarction (MI), and cardiac arrest. RESULTS: 283 patients received MTP between 2010 and 2017. 179 (63%) did not receive TXA and 104 (37%) were treated with TXA. The groups were then propensity matched and yielded 62 patients in each group (124 total) (ISS 36 ±â€¯12 no TXA vs. 37 ±â€¯13 TXA; p = 0.59). There was no significant difference observed in mortality (50% no TXA vs. 39% TXA; p = 0.21), total PRBC's transfused (20 ±â€¯11 no TXA vs. 23 ±â€¯18 TXA; p = 0.45), DVT (8% no TXA vs. 6% TXA; p = 0.99), PE (2% no TXA vs. 3% TXA; p = 0.99), MI (3% no TXA vs. 0% TXA; p = 0.50), or cardiac arrest (26% no TXA vs. 18% TXA; p = 0.28). CONCLUSION: There does not appear to be any benefit to TXA administration in Trauma Patients in our institution. This is a single-center retrospective review. More data from other similar centers in the region or the United States is warranted.

Fatal crashes in the 5 years after recreational marijuana legalization in Colorado and Washington.

Colorado and Washington legalized recreational marijuana in 2012, but the effects of legalization on motor vehicle crashes remains unknown. Using Fatality Analysis Reporting System data, we performed difference-in-differences (DD) analyses comparing changes in fatal crash rates in Washington, Colorado and nine control states with stable anti-marijuana laws or medical marijuana laws over the five years before and after recreational marijuana legalization. In separate analyses, we evaluated fatal crash rates before and after commercial marijuana dispensaries began operating in 2014. In the five years after legalization, fatal crash rates increased more in Colorado and Washington than would be expected had they continued to parallel crash rates in the control states (+1.2 crashes/billion vehicle miles traveled, CI: -0.6 to 2.1, p = 0.087), but not significantly so. The effect was more pronounced and statistically significant after the opening of commercial dispensaries (+1.8 crashes/billion vehicle miles traveled, CI: +0.4 to +3.7, p = 0.020). These data provide evidence of the need for policy strategies to mitigate increasing crash risks as more states legalize recreational marijuana.

Decreasing failed extubations with the implementation of an extubation checklist.

BACKGROUND: Failed extubation has been shown to increase ICU stay, transfers to rehabilitation facilities, and mortality. The purpose of this study was to assess the differences in rates of failed extubation before and after implementation of an extubation checklist. METHODS: We performed a retrospective study from January 2013-April 2017 on adult trauma patients (age 18-89) who were admitted to the ICU and required mechanical ventilation. Patients were grouped before and after implementation of an extubation checklist and compared. RESULTS: A total of 993 patients were included in this study. After checklist implementation, significantly fewer patients required reintubation compared to those prior to checklist (7% vs 3%, p = 0.005). There was no difference in mortality (20% vs 21%, p = 0.54) or hospital length of stay between the two groups (16 days vs 15 days, p = 0.16). CONCLUSION: Our study reveals that implementing an extubation checklist is associated with fewer failed extubations.